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Stiede JT, Spencer SD, Onyeka O, Mangen KH, Church MJ, Goodman WK, Storch EA. Obsessive-Compulsive Disorder in Children and Adolescents. Annu Rev Clin Psychol 2024; 20:355-380. [PMID: 38100637 DOI: 10.1146/annurev-clinpsy-080822-043910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Obsessive-compulsive disorder (OCD) in children and adolescents is a neurobehavioral condition that can lead to functional impairment in multiple domains and decreased quality of life. We review the clinical presentation, diagnostic considerations, and common comorbidities of pediatric OCD. An overview of the biological and psychological models of OCD is provided along with a discussion of developmental considerations in youth. We also describe evidence-based treatments for OCD in childhood and adolescence, including cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) and pharmacotherapy. Finally, research evaluating the delivery of CBT in different formats and modalities is discussed, and we conclude with suggestions for future research directions.
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Affiliation(s)
- Jordan T Stiede
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
| | - Samuel D Spencer
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
| | - Ogechi Onyeka
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
| | - Katie H Mangen
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
| | - Molly J Church
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
| | - Wayne K Goodman
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
| | - Eric A Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA;
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2
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Cervin M, McGuire JF, D'Souza JM, De Nadai AS, Aspvall K, Goodman WK, Andrén P, Schneider SC, Geller DA, Mataix-Cols D, Storch EA. Efficacy and acceptability of cognitive-behavioral therapy and serotonin reuptake inhibitors for pediatric obsessive-compulsive disorder: a network meta-analysis. J Child Psychol Psychiatry 2024; 65:594-609. [PMID: 38171647 DOI: 10.1111/jcpp.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SRIs) are recommended treatments for pediatric obsessive-compulsive disorder (OCD), but their relative efficacy and acceptability have not been comprehensively examined. Further, it remains unclear whether the efficacy of in-person CBT is conserved when delivered in other formats, such as over telephone/webcam or as Internet-delivered CBT (ICBT). METHODS PubMed, PsycINFO, trial registries, and previous systematic reviews were searched for randomized controlled trials (RCTs) comparing CBT (in-person, webcam/telephone-delivered, or ICBT) or SRIs with control conditions or each other. Network meta-analyses were conducted to examine efficacy (post-treatment Children's Yale-Brown Obsessive Compulsive Scale) and acceptability (treatment discontinuation). Confidence in effect estimates was evaluated with CINeMA (Confidence in Network Meta-Analysis). RESULTS Thirty eligible RCTs and 35 contrasts comprising 2,057 youth with OCD were identified. In-person CBT was significantly more efficacious than ICBT, waitlist, relaxation training, and pill placebo (MD range: 3.95-11.10; CINeMA estimate of confidence: moderate) but did not differ significantly from CBT delivered via webcam/telephone (MD: 0.85 [-2.51, 4.21]; moderate), SRIs (MD: 3.07 [-0.07, 6.20]; low), or the combination of in-person CBT and SRIs (MD: -1.20 [-5.29, 2.91]; low). SRIs were significantly more efficacious than pill placebo (MD: 4.59 [2.70, 6.48]; low) and waitlist (MD: 8.03 [4.24, 11.82]; moderate). No significant differences for acceptability emerged, but confidence in estimates was low. CONCLUSIONS In-person CBT and SRIs produce clear benefits compared to waitlist and pill placebo and should be integral parts of the clinical management of pediatric OCD, with in-person CBT overall having a stronger evidence base. The combination of in-person CBT and SRIs may be most efficacious, but few studies hinder firm conclusions. The efficacy of CBT appears conserved when delivered via webcam/telephone, while more trials evaluating ICBT are needed.
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Affiliation(s)
| | | | | | | | - Kristina Aspvall
- Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | | | - Per Andrén
- Lund University, Lund, Sweden
- Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
| | | | | | - David Mataix-Cols
- Lund University, Lund, Sweden
- Karolinska Institutet and Stockholm Health Care Services, Stockholm, Sweden
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3
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Petrie DJ, Meeks KD, Fisher ZF, Geier CF. Associations between somatomotor-putamen resting state connectivity and obsessive-compulsive symptoms vary as a function of stress during early adolescence: Data from the ABCD study. Brain Res Bull 2024; 210:110934. [PMID: 38508468 DOI: 10.1016/j.brainresbull.2024.110934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 03/22/2024]
Abstract
Obsessive-compulsive symptoms (OCS) are relatively common during adolescence although most individuals do not meet diagnostic criteria for obsessive-compulsive disorder (OCD). Nonetheless, OCS during adolescence are associated with comorbid psychopathologies and behavioral problems. Heightened levels of environmental stress and greater functional connectivity between the somatomotor network and putamen have been previously associated with elevated OCS in OCD patients relative to healthy controls. However, the interaction of these factors within the same sample of individuals has been understudied. This study examined somatomotor-putamen resting state connectivity, stress, and their interaction on OCS in adolescents from 9-12 years of age. Participants (n = 6386) were drawn from the ABCD Study 4.0 release. Multilevel modeling was used to account for nesting in the data and to assess changes in OCS in this age range. Stress moderated the association between somatomotor-putamen connectivity and OCS (β = 0.35, S.E. = 0.13, p = 0.006). Participants who reported more stress than their average and had greater somatomotor-left putamen connectivity reported more OCS, whereas participants who reported less stress than their average and had greater somatomotor-left putamen connectivity reported less OCS. These data suggest that stress differentially affects the direction of association between somatomotor-putamen connectivity and OCS. Individual differences in the experience or perception of stress may contribute to more OCS in adolescents with greater somatomotor-putamen connectivity.
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Affiliation(s)
- Daniel J Petrie
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States; Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, United States.
| | - Kathleen D Meeks
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, United States
| | - Zachary F Fisher
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, United States
| | - Charles F Geier
- Department of Human Development and Family Science, University of Georgia, Athens, GA, United States
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4
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Ivarsson T, Jensen S, Højgaard DRMA, Hybel KA, Torp NC, Melin K, Nissen JB, Weidle B, Thomsen PH, Dahl K, Skarphedinsson G. Remission and Relapse Across Three Years in Pediatric Obsessive-Compulsive Disorder Following Evidence-Based Treatments. J Am Acad Child Adolesc Psychiatry 2024; 63:519-527. [PMID: 38070870 DOI: 10.1016/j.jaac.2023.09.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/11/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE To examine relapse rates following remission in a 3-year follow-up study in pediatric patients with obsessive-compulsive disorder (OCD) treated with cognitive-behavioral therapy (CBT) in a first step, and either continued CBT or sertraline (randomized selection) in a second step. METHOD Participants (N = 269) fulfilled DSM-IV OCD criteria with a mean severity on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) of 24.6 (SD = 5.1) and were included in analyses according to intent-to-treat principles. CBT used manualized exposure and response prevention (ERP) during both steps 1 and 2, and step 2 sertraline medication used flexible dosing. The follow-up schedules were timed to 6, 12, 24, and 36 months following step 1 CBT. Remission was defined as a CY-BOCS score ≤10 and relapse as an elevated CY-BOCS score ≥16 in those who had remitted. RESULTS A good third of our patients were in stable and full remission at all examinations (n = 98, 36.4%). Further, some in remission following treatment (n = 36, 13.4%) had mild OCD at some examinations. Relapses during follow-up were not uncommon (n = 28, 10.4%), but in many patients these improved again (n = 10, 3.7%) and were in remission at the final 3-year follow-up. Furthermore, a considerable proportion (n = 50, 18.6%) of the patients were initial non-remitters to the treatment but achieved remission at some point during the follow-up. In addition, 11.5% (n = 31) had persistent OCD but reached remission by the last follow-up. Finally, a smaller segment of our sample (9.7%, n = 26), did not attain remission at any point during the study. CONCLUSION Our outcome paints a more promising picture of pediatric OCD long-term outcome than previous studies have done. However, both relapse rates and the presence of initial non-remitters and persistent OCD show that treatments need improvement, particularly for those who respond slowly, partially, or not at all. The lack of a general psychiatric interview at follow-up is a marked limitation. CLINICAL TRIAL REGISTRATION INFORMATION Nordic Long-term Obsessive compulsive disorder (OCD) Treatment Study; https://www.isrctn.com; ISRCTN66385119.
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Affiliation(s)
- Tord Ivarsson
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.
| | | | | | | | - Nor Christian Torp
- Division of Mental Health Services, Akershus University Hospital, Norway; Division of Mental Health and Addiction, Department of Child and Adolescent Psychiatry, Vestre Viken Hospital, Drammen, Norway
| | - Karin Melin
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Bernhard Weidle
- Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway, and St. Olav's University Hospital, Trondheim, Norway
| | | | - Kitty Dahl
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo
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5
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Zhang W, Yang W, Ruan H, Gao J, Wang Z. Comparison of internet-based and face-to-face cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review and network meta-analysis. J Psychiatr Res 2023; 168:140-148. [PMID: 37907037 DOI: 10.1016/j.jpsychires.2023.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/20/2023] [Accepted: 10/14/2023] [Indexed: 11/02/2023]
Abstract
Cognitive behavioral therapy (CBT) is widely recognized as an effective treatment for obsessive-compulsive disorder (OCD). However, few patients are able to receive CBT. Internet-based CBT (ICBT) may be able to overcome this problem. In this study, we aimed to compare the efficacy of CBT, therapist-guided ICBT (TG-ICBT), unguided ICBT (UG-ICBT), and none therapist-guided ICBT (NTG-ICBT) by a network meta-analysis. The primary outcome was the mean change in OCD severity measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The secondary outcomes included the severity of depressive symptoms, side effects, and cost-effectiveness. A total of 25 trials with 1642 participants were included. We found that the efficacy of CBT was superior to that of TG-ICBT. The mean improvement in Y-BOCS/CY-BOCS scores was higher in CBT group than in UG-ICBT group, but this difference was not statistically significant. The efficacy did not differ significantly between TG-ICBT and UG-ICBT. CBT, TG-ICBT, and UG-ICBT were all more effective than the psychological placebo, waiting list, and pill placebo. In terms of efficacy, CBT combined with drug therapy was better than CBT, TG-ICBT, and UG-ICBT. Sensitivity analyses supported these findings. Based on the current evidence, we recommend TG-ICBT when CBT is not available. However, it is undeniable that UG-ICBT also has the potential to be an effective alternative to CBT. More evidence is needed to support this possibility.
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Affiliation(s)
- Wenxuan Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Weili Yang
- The Second Affiliated Hospital of Xinxiang Medical University, PR China
| | - Hanyang Ruan
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Jian Gao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Zhen Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China; Institute of Psychological and Behavioral Science, Shanghai Jiao Tong University, Shanghai, PR China; Shanghai Intelligent Psychological Evaluation and Intervention Engineering Technology Research Center, Shanghai, PR China.
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6
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Mendez EM, Dahlsgaard KK, Hjelmgren JM, Mills JA, Suresh V, Strawn JR. What Is the Added Benefit of Combining Cognitive Behavioral Therapy and Selective Serotonin Reuptake Inhibitors in Youth with Obsessive Compulsive Disorder? A Bayesian Hierarchical Modeling Meta-Analysis. J Child Adolesc Psychopharmacol 2023; 33:203-211. [PMID: 37347947 PMCID: PMC10458367 DOI: 10.1089/cap.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Background: Treatment of obsessive-compulsive disorder (OCD) in children and adolescents frequently involves cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), or their combination. However, how adding CBT to SSRIs affects the trajectory and magnitude of improvement has not been evaluated meta-analytically. Methods: We performed a meta-analysis using weekly data from prospective randomized parallel group trials of CBT and SSRIs in pediatric patients with OCD. Response was modeled for the change in the Child Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) using a Bayesian hierarchical model over 12 weeks. Results: Fourteen studies included pharmacotherapy arms, 4 studies included combined pharmacotherapy and psychotherapy, and 10 studies included a placebo or control arm. The studies included 1146 patients (mean age 12.7 ± 1.3 years, mean 42.1% female). In the logarithmic model of response, statistically significant differences in treatment effects for CBT+SSRI and SSRI monotherapy were observed compared with placebo (SSRI β = -3.59, credible interval [95% CrI]: -4.13 to -3.02, p < 0.001; SSRI+CBT β = -4.07, 95% CrI: -5.05 to -3.04, p < 0.001). Adding CBT to an SSRI produced numerically (but not statistically significantly) greater improvement over 12 weeks. Greater improvement was observed in studies with more boys (p < 0.001), younger patients (p < 0.001), and in studies with greater baseline symptom severity (p < 0.001). Conclusions: In children and adolescents with OCD, compared with placebo, both SSRIs and SSRI+CBT produced early and sustained improvement over 12 weeks, although the improvement was also related to sample characteristics. Longer term studies are needed to determine when the additive benefit of CBT emerges relative to SSRI monotherapy.
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Affiliation(s)
- Eric M. Mendez
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | | | - John M. Hjelmgren
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey A. Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vikram Suresh
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Divisions of Child & Adolescent Psychiatry and Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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7
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Leuchter JD, Kook M, Geller DA, Hertz AG, Garcia J, Trent ES, Dibbs T, Onyeka O, Goodman WK, Guzick AG, Wiese AD, Palo AD, Small BJ, Simpson HB, Havel LK, Nibras SA, Saxena K, Storch EA. Promoting OCD WEllness and resilience (POWER) study: Rationale, design, and methods. PSYCHIATRY RESEARCH COMMUNICATIONS 2023; 3:100111. [PMID: 37377947 PMCID: PMC10299759 DOI: 10.1016/j.psycom.2023.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Obsessive-compulsive disorder (OCD) affects 1-2% of children and is associated with functional impairment and diminished quality of life. Several treatments are efficacious: cognitive behavioral therapy (CBT) with exposure and response prevention, serotonin reuptake inhibitor (SRI) monotherapy, and combined treatment (SRI + CBT). Expert clinician-informed practice parameters suggest that youth with mild to moderate OCD should be treated initially with CBT yet SRIs are frequently employed as the first-line intervention or in combination with psychotherapy in applied practice. Empirical data to guide SRI discontinuation in pediatric OCD are very limited. This study, Promoting OCD Wellness and Resiliency (POWER), aims to address this gap through a two phase, double-blinded, placebo-controlled, randomized controlled non-inferiority trial with the purpose of evaluating whether youth with OCD on an SRI can discontinue their medication after successful CBT augmentation and maintain wellness for a period of 24 weeks during which they receive maintenance CBT that models standard-of-care. In this paper we describe the rationale and methodological design of the POWER study.
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Affiliation(s)
- Jessica D. Leuchter
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Minjee Kook
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Daniel A. Geller
- Department of Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, MA, USA
| | - Alyssa G. Hertz
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jessica Garcia
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Erika S. Trent
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Tracey Dibbs
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Ogechi Onyeka
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Wayne K. Goodman
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Andrew G. Guzick
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Andrew D. Wiese
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Amanda D. Palo
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Brent J. Small
- School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - H. Blair Simpson
- Department of Psychiatry, Columbia University Medical Center, USA
| | - Lauren K. Havel
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Sohail A. Nibras
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Kirti Saxena
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
- Texas Children’s Hospital, Houston, TX, USA
| | - Eric A. Storch
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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8
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Strouphauer ER, Morris OJ, Soileau KJ, Wiese AD, Quast T, Goodman WK, Sheth SA, Wojcik KD, Guzick AG, Storch EA. Economic Analyses of Obsessive-Compulsive Disorder Interventions: A Systematic Review. PHARMACOECONOMICS 2023; 41:499-527. [PMID: 36840747 DOI: 10.1007/s40273-023-01250-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition featuring patterns of obsessions, compulsions, and avoidant behaviors that are often time consuming and distressing to affected individuals. Cognitive-behavioral therapy (CBT) with exposure and response prevention and/or serotonin reuptake inhibitors are first-line treatments for OCD, though other therapeutic interventions may serve as economically practical modalities under various circumstances. Exploring and understanding the cost effectiveness of all indicated OCD interventions are important to inform therapeutic decisions and provide quality patient-centered care at a cost that is not burdensome to the patient and/or healthcare system. METHODS A systematic literature review was performed and studies were extracted from PubMed, Embase, Ovid MEDLINE, and Cochrane. All cost-effectiveness studies that included economic analyses with respect to OCD treatment modalities and were written in English and published between January 2010 and July 2022 were eligible for inclusion in the present study. We report a narrative synthesis of the findings and quality appraisal of the selected references. RESULTS Of the 707 references returned in the literature search, a total of 18 cost-effectiveness studies were included for review. Compared with treatment as usual, several studies reported clinical superiority and cost effectiveness of Internet-based CBT programs for adults and children with OCD at various willingness-to-pay thresholds and economic reference indicators, though cost effectiveness relative to in-person CBT with exposure and response prevention is unclear and estimates of efficacy are likely lower for Internet-based CBT. One study favored the cost utility of serotonin reuptake inhibitor monotherapy over CBT with exposure and response prevention although efficacy estimates of the former tend to be lower, and relative cost differences were low. Five studies evaluated the cost effectiveness of high-intensity neuroaugmentation, including deep brain stimulation and stereotactic radiosurgical capsulotomy, in the context of treatment-refractory OCD. CONCLUSIONS Despite the relatively high prevalence of OCD worldwide, cost-effectiveness data for therapeutic modalities remain sparse. Because of the chronic nature of OCD, the cost of treatment accumulates and may lead to a significant financial burden over time, particularly when non-evidence-based interventions are used. However, several alternative therapeutic modalities hold promise for economic practicality without significant sacrifice in clinical efficacy. Future studies are necessary to directly compare the cost effectiveness of such therapeutic alternatives with the current standard of care, CBT with exposure and response prevention.
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Affiliation(s)
- Emily R Strouphauer
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Olivia J Morris
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Keaton J Soileau
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Andrew D Wiese
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Troy Quast
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Wayne K Goodman
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Katharine D Wojcik
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Andrew G Guzick
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS: 350, Houston, TX, 77030, USA.
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9
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Schuyler M, Geller DA. Childhood Obsessive-Compulsive Disorder. Psychiatr Clin North Am 2023; 46:89-106. [PMID: 36740357 DOI: 10.1016/j.psc.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Obsessive-compulsive disorder (OCD) frequently affects children and adolescents, with most cases beginning during this time. Symptoms of OCD in youth may present as exaggerated developmental concerns and excessive ritualistic behavior beyond what is part of normal development, yet low levels of insight may prevent recognition. Affected youth commonly have comorbid neurodevelopmental diagnoses, especially males. Early detection and intervention are critical to recovery and remission, as well as family involvement in treatment. Cognitive behavioral therapy and serotonin reuptake inhibitors are first-line treatments.
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Affiliation(s)
- McKenzie Schuyler
- Department of Psychiatry, Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA 02114, USA
| | - Daniel A Geller
- Department of Psychiatry, Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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10
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Trajectory of Change in Parental Accommodation and Its Relation to Symptom Severity and Impairment in Pediatric OCD. Child Psychiatry Hum Dev 2023; 54:232-240. [PMID: 34519945 DOI: 10.1007/s10578-021-01240-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2021] [Indexed: 01/25/2023]
Abstract
Family accommodation (FA) has been shown to relate to poorer treatment outcomes in pediatric obsessive compulsive disorder (OCD), yet few studies have examined the trajectory of change in FA throughout treatment and its relation to treatment outcomes. This study examined change in FA in relation to change in symptom severity and impairment in 63 youth receiving a family-based intervention for early-onset OCD. FA, symptom severity and functional impairment were assessed at baseline, week 5, week 9, and post-treatment (week 14). Results suggested that changes in FA in the beginning stages of treatment preceded global symptom improvement (but not OCD specific improvement) whereas changes in functional impairment preceded changes in FA. In the latter half of treatment, changes in FA preceded improvement in global and OCD specific symptom severity as well as functional impairment. These findings highlight the importance of reducing FA, especially in the later stages of treatment, in order to optimize treatment outcomes in early-onset OCD.
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11
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Suhas S, Malo PK, Kumar V, Issac TG, Chithra NK, Bhaskarapillai B, Reddy YCJ, Rao NP. Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials. World J Biol Psychiatry 2023; 24:162-177. [PMID: 35615998 DOI: 10.1080/15622975.2022.2082525] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Treatment-resistant obsessive-compulsive disorder is a chronic debilitating illness. We conducted a network meta-analysis [NMA] to compare the efficacy of all interventions in SRI-resistant OCD from published Randomised controlled trials [RCT]. METHODS We performed an NMA of RCTs in SRI resistant OCD from all modalities of treatments; pharmacological, psychological, neuromodulation, neurosurgery including deep brain stimulation. The design-by-treatment interaction inconsistency model within the frequentist framework was adopted with a change in Yale-Brown Obsessive-Compulsive Scale score as the primary outcome. We conducted sensitivity analyses excluding studies examining neurosurgical interventions, deep brain stimulation, studies in the paediatric population, and studies from a single geographical region. We also conducted analyses of interventions categorised into treatment groups. RESULTS 55 RCTs examining 19 treatments or placebo involving 2011 participants were included in the NMA. Ondansetron [Standardised mean difference -2.01 (95% CI: -3.19, -0.83)], deep TMS [- 1.95 (-3.25, -0.65)], therapist administered Cognitive Behavioural Therapy [CBT-TA] [-1.46 (-2.93, 0.01)] and aripiprazole [-1.36 (-2.56, -0.17)] were ranked as the best four treatments on using the Surface Under the Cumulative Ranking [SUCRA] percentage values (85.4%, 83.2%, 80.3%, 67.9% respectively). While all four interventions had large effect sizes, CBT[TA] narrowly missed statistical significance in our analysis. In sensitivity analyses, deep TMS was ranked as the best treatment strategy for SRI-resistant OCD. The small number of subjects in individual studies, higher confidence interval limits, and wider prediction interval for most agents warrant a cautious interpretation. CONCLUSIONS Considering the principal analysis and sensitivity analyses together, deep TMS, ondansetron, CBT[TA], and aripiprazole may be considered a first-line intervention for SRI-resistant OCD in adults. OTHER This work was not funded. The NMA has been registered with PROSPERO, [Registration number: CRD42020173589].
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Affiliation(s)
- Satish Suhas
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Palash Kumar Malo
- Department of Biostatistics, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Vijay Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Thomas Gregor Issac
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Nellai K Chithra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Binukumar Bhaskarapillai
- Department of Biostatistics, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Y C Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Naren P Rao
- Department of Psychiatry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
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Conelea CA, Morris S, McLaughlin N, Mamaril E, Benito K, Case B, Garcia A. Response Inhibition in Youth Undergoing Intensive Treatment for Obsessive Compulsive Disorder. J Obsessive Compuls Relat Disord 2023; 36:100764. [PMID: 36644665 PMCID: PMC9835685 DOI: 10.1016/j.jocrd.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Response Inhibition (RI) is the ability to suppress behaviors that are inappropriate for a given context. Obsessive-compulsive disorder (OCD) has been associated with impaired RI in adults as measured by the Stop Signal Task (SST). Conflicting results have been found in terms of the relationship between OCD severity and SST performance, and no studies to date have examined the relationship between SST and response to OCD treatment. Also relatively unknown is whether RI performance in OCD is associated with developmental or gender differences. This naturalistic study examined the relationship between SST performance, OCD severity, and OCD treatment response in a pediatric sample undergoing intensive treatment involving exposure and response prevention and medication management (n = 36). The SST and Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS) were administered at admission and program discharge. OCD severity was not significantly related to stop signal reaction time (SSRT) in the whole sample and among subgroups divided by age and gender. Baseline SSRT and SSRT change did not predict CYBOCS change across treatment in the whole sample, but exploratory analyses indicated both were significant predictors among female adolescents. Results suggest there may be developmental gender differences in the relationship between RI and clinical improvement in pediatric OCD.
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Affiliation(s)
- Christine A. Conelea
- University of Minnesota, Department of Psychiatry and Behavioral Sciences, Minneapolis, MN, USA
- Masonic Institute for the Developing Brain, Minneapolis, MN, USA
| | - Sarah Morris
- Bradley Hospital, Pediatric Anxiety Research Center, East Providence, RI, USA
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
| | - Nicole McLaughlin
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
- Butler Hospital, Providence, RI, USA
| | - Erin Mamaril
- Bradley Hospital, Pediatric Anxiety Research Center, East Providence, RI, USA
| | - Kristen Benito
- Bradley Hospital, Pediatric Anxiety Research Center, East Providence, RI, USA
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
| | - Brady Case
- Bradley Hospital, Pediatric Anxiety Research Center, East Providence, RI, USA
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
| | - Abbe Garcia
- Bradley Hospital, Pediatric Anxiety Research Center, East Providence, RI, USA
- Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
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Adam J, Goletz H, Dengs S, Klingenberger N, Könnecke S, Vonderbank C, Hautmann C, Hellmich M, Plück J, Döpfner M. Extended treatment of multimodal cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder improves symptom reduction: a within-subject design. Child Adolesc Psychiatry Ment Health 2022; 16:99. [PMID: 36494821 PMCID: PMC9737735 DOI: 10.1186/s13034-022-00537-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Based on the current state of research regarding the treatment in pediatric obsessive-compulsive disorder (OCD), cognitive behavioral therapy (CBT) (in severe cases with additional pharmacotherapy) is considered as the first-line treatment according to internationally recognized guidelines. Research is mostly based on randomized controlled trials (RCTs; efficacy research). Thus, examined treatment conditions, especially the treatment duration, and patients' characteristics do not necessarily correspond to those found within routine care. Studies showed CBT packages as a whole to be efficacious, but less is known about the effects of individual CBT components. Furthermore, effects on comorbid symptoms or psychosocial impairment have been often neglected and different rater perspectives have been hardly considered in previous research. METHODS This effectiveness study aimed to examine the effects of multimodal CBT in children, adolescents, and young adults (age 6-20 years) with OCD (n = 38) within routine care. Effects on obsessive-compulsive and co-existing symptoms were evaluated in a within-subject design by comparing changes during the assessment phase with 12-week standard treatment and with individually tailored extended treatment. Additionally, within the standard treatment, non-exposure treatment was compared to exposure treatment. Multi-informant assessment was applied, and the analyses included multilevel modeling and t-tests for pre-post comparisons. RESULTS During the standard treatment and extended treatment, obsessive-compulsive symptoms, strain, and functional impairment significantly decreased. Moreover, a significant reduction of overall comorbid symptoms emerged, particularly regarding internalizing symptoms, including anxiety and depression. Comparisons of treatment components indicated that adding exposure with response prevention (ERP) has an additional positive effect. Clinical improvement and remission rates increased considerably when more treatment sessions were provided. CONCLUSIONS These results suggest that improvement after an initial 12-week course of treatment may not allow for the prediction of non-responders/non-remitters and for the termination of treatment. Overall, the findings show that results from randomized controlled trials are transferrable to routine care. Trial registration number This study was registered retrospectively at the German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00030050 ).
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Affiliation(s)
- Julia Adam
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969, Cologne, Germany.
| | - Hildegard Goletz
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Stefanie Dengs
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Nora Klingenberger
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Sonja Könnecke
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Christina Vonderbank
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Christopher Hautmann
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Martin Hellmich
- grid.6190.e0000 0000 8580 3777Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Robert-Koch-Str. 10, 50931 Cologne, Germany
| | - Julia Plück
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany
| | - Manfred Döpfner
- grid.6190.e0000 0000 8580 3777School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Pohligstr. 9, 50969 Cologne, Germany ,grid.6190.e0000 0000 8580 3777Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Robert-Koch-Str. 10, 50931 Cologne, Germany
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Frank HE, Kemp J, Benito KG, Freeman JB. Precision Implementation: An Approach to Mechanism Testing in Implementation Research. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:1084-1094. [PMID: 36167942 DOI: 10.1007/s10488-022-01218-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/18/2022] [Indexed: 01/25/2023]
Abstract
Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum - with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings.
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Affiliation(s)
- Hannah E Frank
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 700 Butler Drive, 02906, Providence, RI, USA.
- Bradley Hospital, Lifespan Health System, 1011 Veterans Memorial Parkway, 02915, Riverside, RI, USA.
| | - Joshua Kemp
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 700 Butler Drive, 02906, Providence, RI, USA
- Bradley Hospital, Lifespan Health System, 1011 Veterans Memorial Parkway, 02915, Riverside, RI, USA
| | - Kristen G Benito
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 700 Butler Drive, 02906, Providence, RI, USA
- Bradley Hospital, Lifespan Health System, 1011 Veterans Memorial Parkway, 02915, Riverside, RI, USA
| | - Jennifer B Freeman
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, 700 Butler Drive, 02906, Providence, RI, USA
- Bradley Hospital, Lifespan Health System, 1011 Veterans Memorial Parkway, 02915, Riverside, RI, USA
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Adam J, Goletz H, Viefhaus P, Woitecki K, Döpfner M. Webcam-Based Online Coaching with Children and Adolescents with Obsessive-Compulsive Disorders – A Single-Case Study. ZEITSCHRIFT FÜR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2022; 51:207-221. [PMID: 36259642 DOI: 10.1024/1422-4917/a000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract. Objective: Although there is clear evidence-based knowledge regarding state-of-the-art treatment for pediatric obsessive-compulsive disorder (OCD), two main issues remain in clinical practice: (1) Exposure-based cognitive behavioral therapy (CBT) is limited in terms of availability and accessibility or is not adequately provided, and (2) despite large effect sizes of exposure-based CBT, the achieved recovery rates of 50–60 % still show room for improvement. These issues have prompted an increasing focus on delivering exposure-based CBT in new and innovative ways. This study aims to evaluate an intensive therapist-administered online coaching program consisting of exposure with response prevention via video teleconferencing (VTC) as an add-on to weekly outpatient CBT (blended therapy). Method: The blended therapy is examined in n = 5 children and adolescents with OCD using an AB design and multi-informant ratings. Results: This single-case study shows promising results, indicating that a decrease in OCD severity and related functional impairment can be attributed to blended therapy. Moreover, satisfaction with online coaching was high. Conclusions: Despite some principal limitations, the results support the effectiveness and feasibility of blended therapy.
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Affiliation(s)
- Julia Adam
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Hildegard Goletz
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Paula Viefhaus
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Katrin Woitecki
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Manfred Döpfner
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
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Nezgovorova V, Reid J, Fineberg NA, Hollander E. Optimizing first line treatments for adults with OCD. Compr Psychiatry 2022; 115:152305. [PMID: 35325671 DOI: 10.1016/j.comppsych.2022.152305] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/16/2022] [Accepted: 02/28/2022] [Indexed: 11/03/2022] Open
Abstract
OCD is characterized by obsessions (recurrent, intrusive, unwanted thoughts, images or impulses and compulsions (repetitive behaviors or mental acts that the individual feels compelled to perform), which can manifest together or separately (Fineberg et al., 2020). NICE guidelines suggest that low intensity psychological treatments (including ERP) is the first line treatment for OCD, and that a "stepped care" treatment approach for OCD reserves combination treatment for adults with OCD with severe functional impairment, and for adults without an adequate response to: 1) treatment with an SSRI alone (12 weeks duration) or 2) CBT (including ERP) alone (NICE, 2005). Existing US treatment guidelines (APA guidelines) suggest that there are three first-line treatments for OCD (SSRI, CBT, SSRI+CBT) and recommends combined treatment for patients with an unsatisfactory response to monotherapy or for patients with severe OCD. Although, systematic review and meta-analysis of studies published in 1993-2014 suggest that combination treatment was not significantly better than CBT plus placebo (Ost et al., 2015), based on data from a recent systematic and meta-analysis which searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group, the combination treatment approach is likely to be more effective than psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder (Skapinakis et al., 2016a). Based on data from Optimal treatment for OCD study conducted by Fineberg et al., (2018) combined treatment appeared to be the most effective especially when compared to CBT monotherapy, but SSRI monotherapy was found as the most cost effective. In this review we summarize available treatment recommendations.
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Affiliation(s)
- V Nezgovorova
- Autism and Obsessive-Compulsive Spectrum Disorders Program, Psychiatric Research Institute of Montefiore-Einstein, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - J Reid
- Center for Clinical & Health Research Services, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Welwyn Garden City, Hertfordshire, UK
| | - N A Fineberg
- Center for Clinical & Health Research Services, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Welwyn Garden City, Hertfordshire, UK; University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - E Hollander
- Autism and Obsessive-Compulsive Spectrum Disorders Program, Psychiatric Research Institute of Montefiore-Einstein, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States.
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17
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Farhat LC, Vattimo EFQ, Ramakrishnan D, Levine JLS, Johnson JA, Artukoglu BB, Landeros-Weisenberger A, Asbahr FR, Cepeda SL, Comer JS, Fatori D, Franklin ME, Freeman JB, Geller DA, Grant PJ, Goodman WK, Heyman I, Ivarsson T, Lenhard F, Lewin AB, Li F, Merlo LJ, Mohsenabadi H, Peris TS, Piacentini J, Rosa-Alcázar AI, Rosa-Alcázar À, Rozenman M, Sapyta JJ, Serlachius E, Shabani MJ, Shavitt RG, Small BJ, Skarphedinsson G, Swedo SE, Thomsen PH, Turner C, Weidle B, Miguel EC, Storch EA, Mataix-Cols D, Bloch MH. Systematic Review and Meta-analysis: An Empirical Approach to Defining Treatment Response and Remission in Pediatric Obsessive-Compulsive Disorder. J Am Acad Child Adolesc Psychiatry 2022; 61:495-507. [PMID: 34597773 DOI: 10.1016/j.jaac.2021.05.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 05/05/2021] [Accepted: 09/21/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes. METHOD A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively. RESULTS The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8). CONCLUSION Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD.
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Affiliation(s)
- Luis C Farhat
- Faculdade de Medicina FMUSP, Universidade de São Paulo, Brazil
| | | | - Divya Ramakrishnan
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Jessica L S Levine
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | - Jessica A Johnson
- Columbia University New York, New York; Columbia School of Nursing, New York
| | | | | | | | | | - Jonathan S Comer
- Center for Children and Families, Florida International University, Miami, Florida
| | - Daniel Fatori
- Faculdade de Medicina FMUSP, Universidade de São Paulo, Brazil
| | - Martin E Franklin
- University of Pennsylvania, Philadelphia; Rogers Memorial Hospital, Oconomowoc, Wisconsin
| | - Jennifer B Freeman
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Daniel A Geller
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Isobel Heyman
- Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Tord Ivarsson
- Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Fabian Lenhard
- Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Sweden
| | - Adam B Lewin
- University of South Florida, Hillsborough County
| | - Fenghua Li
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut
| | | | - Hamid Mohsenabadi
- Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, IR
| | - Tara S Peris
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles
| | | | | | | | | | - Eva Serlachius
- Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Sweden
| | - Mohammad J Shabani
- Tehran Institute of Psychiatry, Iran University of Medical Sciences, Tehran, IR
| | | | - Brent J Small
- School of Aging Studies, University of South Florida, Hillsborough County
| | | | | | - Per Hove Thomsen
- Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Aarhus University Hospital, Skejby, Denmark
| | - Cynthia Turner
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Bernhard Weidle
- Regional Center for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; St. Olav's University Hospital, Trondheim, Norway
| | | | | | - David Mataix-Cols
- Centre for Psychiatry Research, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Sweden
| | - Michael H Bloch
- Yale Child Study Center, Yale School of Medicine, New Haven, Connecticut.
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Harvey AM, Wojcik KD, Wiese AD, Goodman WK, Storch EA. Management of OCD: Focus on Psychotherapy. Psychiatr Ann 2022. [DOI: 10.3928/00485713-20220308-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Şimşek MK, Seçer İ. Developing and Examining the Effectiveness of a Cognitive Behavioral Therapy-Based Psychoeducation Practice for Reducing Obsessive-Compulsive Symptoms in Adolescents: A Mixed-Methods Study With a Turkish Sample. Front Psychol 2022; 13:805035. [PMID: 35330724 PMCID: PMC8940527 DOI: 10.3389/fpsyg.2022.805035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
This study developed a cognitive behavioral therapy (CBT)-based psychoeducation practice aimed at reducing obsessive-compulsive symptom levels in adolescents in Turkey and tested its effectiveness with a mixed-methods study. After the study was constructed as a pretest-posttest control group experimental application consisting of qualitative stages. The experimental application of the study was carried out with high school students in Turkey. In the sampling process, the schools, where the study will be carried out, were determined with the cluster sampling method. The experimental and control groups were formed with 30 students with high obsessive-compulsive disorder (OCD) symptoms from these schools, and the developed CBT-based psychoeducation practice was applied to the experimental group for 12 weeks. Quantitative data were collected through the "Child Version of the Obsessive-Compulsive Inventory," and normality analysis, t-test for dependent samples, and Single Factor Analysis of Covariance were used. Qualitative data of the study were collected through document review, session evaluation forms, and semi-structured interview protocol; content and descriptive analysis techniques were used in the analysis. It was concluded that the developed CBT-based psychoeducation application was an effective approach in reducing OCD symptoms in the Turkish adolescent sample, except for the neutralizing dimension. It was also determined that the findings obtained from the analysis during the application and the interviews after the application are parallel with the findings obtained by quantitative methods, and the qualitative and quantitative findings adequately explained the quantitative documents findings.
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Affiliation(s)
| | - İsmail Seçer
- Faculty of Education, Counseling and Guidance, Atatürk University, Erzurum, Turkey
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Katz TC, Bui TH, Worhach J, Bogut G, Tomczak KK. Tourettic OCD: Current understanding and treatment challenges of a unique endophenotype. Front Psychiatry 2022; 13:929526. [PMID: 35966462 PMCID: PMC9363583 DOI: 10.3389/fpsyt.2022.929526] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Obsessive compulsive disorder (OCD) and chronic tic disorders (CTD) including Tourette Syndrome (TS) are often comorbid conditions. While some patients present with distinct symptoms of CTD and/or OCD, a subset of patients demonstrate a unique overlap of symptoms, known as Tourettic OCD (TOCD), in which tics, compulsions, and their preceding premonitory urges are overlapping and tightly intertwined. The specific behaviors seen in TOCD are typically complex tic-like behaviors although with a compulsive and partially anxious nature reminiscent of OCD. TOCD is not classified within the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) as an independent diagnostic entity, but mounting evidence suggests that TOCD is an intermediate neuropsychiatric disorder distinct from either TS or OCD alone and as such represents a unique phenomenology. In this review of TOCD we discuss clinical, genetic, environmental, neurodevelopmental, and neurocircuit-based research to better characterize our current understanding of this disorder. TOCD is characterized by earlier age of onset, male predominance, and specific symptom clusters such as lower tendency toward compulsions related to checking, cleaning, and reassurance seeking and higher tendency toward compulsions such as rubbing, tapping, or touching associated with symmetry concerns or thoughts of exactness. Functional magnetic resonance imaging (fMRI) imaging suggests that TOCD symptoms may arise from involvement of an intermediate neurocircuitry distinct from classic OCD or classic CTD. Small cumulative contributions from multiple genetic loci have been implicated, as have environmental factors such as infection and perinatal trauma. In addition, this review addresses the treatment of TOCD which is especially complex and often treatment resistant and requires pharmacology and behavioral therapy in multiple modalities. Given the distressing impact of TOCD on patients' functioning, the goal of this review is to raise awareness of this distinct entity toward the goal of improving standards of care.
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Affiliation(s)
- Tamar C Katz
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, United States
| | - Thanh Hoa Bui
- Tic Disorders and Tourette Syndrome Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Jennifer Worhach
- Tic Disorders and Tourette Syndrome Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Gabrielle Bogut
- Tic Disorders and Tourette Syndrome Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Kinga K Tomczak
- Tic Disorders and Tourette Syndrome Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
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21
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Babiano-Espinosa L, Wolters LH, Weidle B, Compton SN, Lydersen S, Skokauskas N. Acceptability and feasibility of enhanced cognitive behavioral therapy (eCBT) for children and adolescents with obsessive-compulsive disorder. Child Adolesc Psychiatry Ment Health 2021; 15:47. [PMID: 34481523 PMCID: PMC8418719 DOI: 10.1186/s13034-021-00400-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 08/27/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Obsessive-compulsive disorder (OCD) is a disabling mental health disorder affecting 1-3% of children and adolescents. Cognitive behavioral therapy (CBT) is recommended as the first-line treatment, but is limited by accessibility, availability, and, in some cases, response to treatment. Enhancement with Internet technologies may mitigate these challenges. METHODS We developed an enhanced CBT (eCBT) treatment package for children and adolescents with OCD to improve treatment effect as well as user-friendliness. This study aims to explore the feasibility, acceptability, and preliminary effectiveness of the eCBT intervention. The eCBT protocol consists of 10 face-to-face and 12 webcam sessions delivered in 14 weeks. CBT is enhanced by a smartphone application (app) for children and parents to support and monitor treatment, psychoeducative videos, and therapist-guided webcam exposure exercises conducted at home. Assessments were performed at baseline, post-treatment, and at 3- and 6-month follow-up. Primary measures of outcomes were the the Client Satisfaction Questionnaire-8 (CSQ-8) (acceptability), treatment drop-out (feasibility) and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) (preliminary effectiveness). RESULTS This paper describes 25 patients with OCD (aged 8-17 years) treated with eCBT. Results indicated that children and parents were satisfied with eCBT, with CSQ-8 mean scores of 27.58 (SD 0.67) and 29.5 (SD 3.74), respectively (range 8-32). No patients dropped out from treatment. We found a mean of 63.8% symptom reduction on the CY-BOCS from baseline to post-treatment. CY-BOCS scores further decreased during 3-month and 6-month follow-up. CONCLUSION In this explorative study, eCBT for pediatric OCD was a feasible, acceptable intervention demonstrating positive treatment outcomes.
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Affiliation(s)
- Lucía Babiano-Espinosa
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway ,grid.52522.320000 0004 0627 3560Department of Child and Adolescent Psychiatry, St. Olav’s University Hospital, Trondheim, Norway
| | - Lidewij H. Wolters
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bernhard Weidle
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway ,grid.52522.320000 0004 0627 3560Department of Child and Adolescent Psychiatry, St. Olav’s University Hospital, Trondheim, Norway
| | - Scott N. Compton
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Stian Lydersen
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway ,grid.52522.320000 0004 0627 3560Department of Child and Adolescent Psychiatry, St. Olav’s University Hospital, Trondheim, Norway
| | - Norbert Skokauskas
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway. .,Department of Child and Adolescent Psychiatry, St. Olav's University Hospital, Trondheim, Norway.
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Cyr M, Pagliaccio D, Yanes-Lukin P, Goldberg P, Fontaine M, Rynn MA, Marsh R. Altered fronto-amygdalar functional connectivity predicts response to cognitive behavioral therapy in pediatric obsessive-compulsive disorder. Depress Anxiety 2021; 38:836-845. [PMID: 34157177 PMCID: PMC8328961 DOI: 10.1002/da.23187] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/29/2021] [Accepted: 05/22/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Based on findings from adults with obsessive-compulsive disorder (OCD), this study examined alterations in resting-state functional connectivity (rs-fc) between the basolateral amygdala (BLA) and the ventromedial prefrontal cortex (vmPFC) in children and adolescents with OCD. We also assessed whether such BLA-vmPFC connectivity changed with or predicted response to exposure and response prevention (E/RP), the first-line treatment for pediatric OCD, given the involvement of these regions in fear processing, regulation, and extinction learning-a probable mechanism of action of E/RP. METHODS Resting state functional magnetic resonance imaging scans were acquired from 25 unmedicated, treatment-naïve pediatric patients with OCD (12.8 ± 2.9 years) and 23 age- and sex-matched healthy controls (HCs; 11.0 ± 3.3 years). Patients completed a 12-16-week E/RP intervention for OCD. Participants were rescanned after the 12-16-week period. ANCOVAs tested group differences in baseline rs-fc. Cross-lagged panel models examined relationships between BLA-vmPFC rs-fc and OCD symptoms pre- and posttreatment. All tests were adjusted for participants' age, sex, and head motion. RESULTS Right BLA-vmPFC rs-fc was significantly reduced (more negative) in patients with OCD relative to HCs at baseline, and increased following treatment. In patients, more positive (less negative) right BLA-vmPFC rs-fc pretreatment predicted greater OCD symptoms reduction posttreatment. Changes in BLA-vmPFC rs-fc was unassociated with change in OCD symptoms pre- to posttreatment. CONCLUSIONS These results provide further evidence of the BLA-vmPFC pathway as a potential target for novel treatments or prevention strategies aimed at facilitating adaptive learning and fear extinction in children with OCD or subclinical OCD symptoms.
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Affiliation(s)
- Marilyn Cyr
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - David Pagliaccio
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Paula Yanes-Lukin
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Pablo Goldberg
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Martine Fontaine
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Moira A. Rynn
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rachel Marsh
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Ashkan K, Mirza AB, Tambirajoo K, Furlanetti L. Deep brain stimulation in the management of paediatric neuropsychiatric conditions: Current evidence and future directions. Eur J Paediatr Neurol 2021; 33:146-158. [PMID: 33092983 DOI: 10.1016/j.ejpn.2020.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/21/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Neurosurgery has provided an alternative option for patients with refractory psychiatric indications. Lesion procedures were the initial techniques used, but deep brain stimulation (DBS) has the advantage of relative reversibility and adjustability. This review sets out to delineate the current evidence for DBS use in psychiatric conditions, with an emphasis on the paediatric population, highlighting pitfalls and opportunities. METHODS A systematic review of the literature was conducted on studies reporting the use of DBS in the management of psychiatric disorders. The PRISMA guidelines were employed to structure the review of the literature. Data was discussed focusing on the indications for DBS management of psychiatric conditions in the paediatric age group. RESULTS A total of seventy-three full-text papers reported the use of DBS surgery for the management of psychiatric conditions matching the inclusion criteria. The main indications were Tourette Syndrome (GTS) (15 studies), Obsessive Compulsive Disorder (OCD) (20), Treatment Resistant Depression (TRD) (27), Eating Disorders (ED) (7) and Aggressive Behaviour and self-harm (AB) (4). Out of these, only 11 studies included patients in the paediatric age group (≤18 years-old). Among the paediatric patients, the indications for surgery included GTS, AB and ED. CONCLUSIONS The application of deep brain stimulation for psychiatric indications has progressed at a steady pace in the adult population and at a much slower pace in the paediatric population. Future studies in children should be done in a trial setting with strict and robust criteria. A move towards personalising DBS therapy with new stimulation paradigms will provide new frontiers and possibilities in this growing field.
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Affiliation(s)
- Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Kantharuby Tambirajoo
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK
| | - Luciano Furlanetti
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; King's Health Partners Academic Health Sciences Centre, London, UK.
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Fletcher J, Dimitropoulos G, Martino D, Wilcox G, MacMaster F, Arnold P, Pringsheim T. Developing a provincial patient support network for children and families affected by Tourette syndrome and/or obsessive-compulsive disorder: results of a stakeholder consultation. Child Adolesc Psychiatry Ment Health 2021; 15:29. [PMID: 34134722 PMCID: PMC8208059 DOI: 10.1186/s13034-021-00383-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tourette syndrome and OCD are disorders that frequently occur in children and cause a high level of disability. In Alberta there is a huge delivery gap in providing healthcare services for children with TS and OCD. A stakeholder consultation was performed to ascertain how service delivery could be improved across the province and to inform the development of a provincial information and support organization, the Tourette OCD Alberta Network. METHODS A mixed-methods study was employed: 10 parents were recruited for interview and 140 parents responded to a survey. RESULTS Qualitative data showed there was often an absence of a clear pathway to access healthcare for people with TS and OCD. The negative impact of not receiving treatment, information, and resources in a timely and prompt manner was also revealed. Good clinical practice existed across the province but too often it was hindered by a shortage of knowledge about TS and OCD. In schools, learning for students with TS and OCD was also impaired by educators' lack of knowledge and preparedness in relation to the disorders. CONCLUSIONS This study identified ways that challenges with healthcare access, school learning, and seeking information can be overcome. Skills-based training webinars, educational outreach in schools, and peer support were recognized as actions for improving healthcare outcomes for people with TS and OCD. The aim of the Tourette OCD Alberta Network is to provide services and support that directly address the healthcare service delivery shortfalls shown in this study.
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Affiliation(s)
- Julian Fletcher
- grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Gina Dimitropoulos
- grid.22072.350000 0004 1936 7697Faculty of Social Work, University of Calgary, Calgary, Canada
| | - Davide Martino
- grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Gabrielle Wilcox
- grid.22072.350000 0004 1936 7697Werklund School of Education, University of Calgary, Calgary, Canada
| | - Frank MacMaster
- grid.22072.350000 0004 1936 7697Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Paul Arnold
- grid.22072.350000 0004 1936 7697Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Tamara Pringsheim
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Mathison Centre for Mental Health Education and Research, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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25
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Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder. Psychiatry Res 2021; 299:113858. [PMID: 33770712 DOI: 10.1016/j.psychres.2021.113858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/06/2021] [Indexed: 12/28/2022]
Abstract
Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.
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26
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Benito KG, Machan J, Freeman JB, Garcia AM, Walther M, Frank H, Wellen B, Stewart E, Edmunds J, Sapyta J, Franklin ME. Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD. Behav Ther 2021; 52:523-538. [PMID: 33990231 PMCID: PMC8124089 DOI: 10.1016/j.beth.2020.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 07/07/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022]
Abstract
This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach-and less use of accommodation, unrelated talk, and externalizing language-predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher "total dose" of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the "black box" of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.
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Affiliation(s)
| | - Jason Machan
- Lifespan Biostatistics Core, Lifespan Hospitals; Warren Alpert Medical School of Brown University; University of Rhode Island
| | | | | | | | | | | | | | - Julie Edmunds
- Massachusetts General Hospital, Harvard Medical School
| | | | - Martin E Franklin
- Perelman School of Medicine, University of Pennsylvania, & Rogers Behavioral Health
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Alpert E, Hayes AM, Yasinski C, Webb C, Deblinger E. Processes of Change in Trauma-Focused Cognitive Behavioral Therapy for Youth: An Emotional Processing Theory Informed Approach. Clin Psychol Sci 2021; 9:270-283. [PMID: 33758692 DOI: 10.1177/2167702620957315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study examines processes of change in trauma-focused cognitive behavioral therapy (TF-CBT) delivered to a community sample of 81 youth. Emotional processing theory (EPT) is used as an organizational framework. EPT highlights activating and changing pathological trauma-related responses and increasing adaptive responses across cognitive, emotional, behavioral, and physiological domains. We coded sessions during the trauma processing phase of TF-CBT to examine the extent to which pathological and adaptive trauma-related responses were activated across domains. Higher scores indicate that more domains (0-4) were activated at a threshold of moderate to high intensity. Curvilinear change (inverted U, increase then decrease) in multimodal negative response scores across sessions predicted improvement in internalizing and PTSD symptoms at posttreatment. Linear increases in multimodal positive responses predicted improvement in externalizing symptoms. Findings suggest value in activating and changing both pathological and adaptive trauma responses across multiple domains and examining nonlinear patterns of change.
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Affiliation(s)
- Elizabeth Alpert
- University of Delaware, Department of Psychological and Brain Sciences
| | - Adele M Hayes
- University of Delaware, Department of Psychological and Brain Sciences
| | - Carly Yasinski
- Emory University, Department of Psychiatry and Behavioral Sciences
| | - Charles Webb
- State of Delaware Division of Prevention and Behavioral Health Services
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28
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Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder. Curr Top Behav Neurosci 2021; 49:301-329. [PMID: 33590457 DOI: 10.1007/7854_2020_202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Obsessive-Compulsive Disorder is an important cause of global health-related disability. In the last several decades, exposure and response prevention (EX/RP) has emerged as one of the most evidence-based treatments for adult and pediatric OCD. Recommended as a first-line treatment in practice guidelines for OCD, EX/RP, when expertly delivered, can be superior to serotonin reuptake inhibitor (SRI) medications alone and superior to adding antipsychotic medication to augment SRI treatment response. Despite a robust evidence base, EX/RP is not widely available. Moreover, although effective, only about half of patients who receive a standard course of EX/RP will achieve remission.This chapter will review innovations in delivering EX/RP, focusing on technology-based methods designed to increase access to EX/RP and translational neuroscience approaches to personalizing and optimizing EX/RP. Technology-based innovations to deliver EX/RP include video conferencing, internet-based treatment, and smartphone apps. Of these, internet-based, clinician-supported treatment has the most evidence base to date. Relevant to all technology-based innovations are the need for advances in the ethical, regulatory and financial aspects of understanding how access to EX/RP may be delivered to individuals of diverse socioeconomic backgrounds in accordance with professional standards and regulations and covered by healthcare.Advances in our understanding of the neural processes underlying learning and memory have led to new ways to combine EX/RP with medications, behavioral interventions, or neuromodulatory methods, with the goal of enhancing the functioning of brain circuits that subserve fear processing and cognitive control. Among the pharmacological approaches to enhancing EX/RP outcome, both ketamine and cannabinoids show promise in small open trials but are in need of further study. Studies to train cognitive control are at an early stage of development yet provide preliminary evidence that training neural processes may be a new path to personalize treatment. How best to combine EX/RP with different types of neuromodulation is being actively studied.Together these innovations in the delivery of EX/RP for OCD hold great promise for improving outcomes of care for individuals with OCD by increasing the availability and the individual treatment effects of this already effective treatment.
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Dop D, Marcu IR, Padureanu R, Niculescu CE, Padureanu V. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (Review). Exp Ther Med 2021; 21:94. [PMID: 33363605 PMCID: PMC7725005 DOI: 10.3892/etm.2020.9526] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/26/2020] [Indexed: 12/04/2022] Open
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinically characterized by the sudden onset of obsessive-compulsive manifestations, motor and verbal tics, as well as other behavioral symptoms in a group of children with B-hemolytic streptococcal infection. PANDAS are considered autoimmune diseases because the streptococcal infection and response can be demonstrated. The most frequent physiopathological mechanism is molecular mimicry: A foreign antigen shares sequence or structural similarities with self-antigens. A thorough review of the literature was carried out using the PubMed database and SCOPUS, searching for immunological, clinical and microbiological aspects, as well as the treatment of the PANDAS syndrome. The diagnosis is clinical and it requires a careful medical history and a thorough physical examination, while the treatment is complex. Untreated or unrecognized manifestations of PANDAS can increase the risk of obsessive-compulsive manifestations and tics during adulthood. Taking this into consideration, further studies are required to establish the best method of therapy.
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Affiliation(s)
- Dalia Dop
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Iulia Rahela Marcu
- Department of Physical and Rehabilitation Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Rodica Padureanu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Carmen Elena Niculescu
- Department of Pediatrics, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
| | - Vlad Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania
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Georgiadis C, Schreck M, Gervasio M, Kemp J, Freeman J, Garcia A, Case B. Disgust propensity and sensitivity in childhood anxiety and obsessive-compulsive disorder: Two constructs differentially related to obsessional content. J Anxiety Disord 2020; 76:102294. [PMID: 32916505 DOI: 10.1016/j.janxdis.2020.102294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 11/25/2022]
Abstract
The role of disgust in anxiety and related disorders has been extensively studied in adults, however its role in childhood psychopathology is in need of further investigation. The adult literature has suggested that two distinct sub-constructs within "disgust proneness" may differentially predict anxiety-related disorders. Namely, disgust propensity (DP) has been defined as the likelihood an individual will experience a disgust reaction, and disgust sensitivity (DS) as the degree to which an individual is distressed by their experience of disgust. The current study aimed to validate the Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) in a sample of youth receiving intensive services for OCD and anxiety, examine the relationship between disgust sub-constructs and obsessional content in a sample of youth with OCD, and examine the relationship between disgust change and symptom severity at discharge. A confirmatory factor analysis supported a two-factor structure of the DPSS-R. DP was found to be uniquely predictive of contamination obsessions, and DS was found to be uniquely predictive of moral obsessions. Lastly, change in DP, but not DS, predicted overall change in OCD symptom severity. The present study provides a valid measure of DS and DP in youth with anxiety and related disorders, and suggests that subconstructs of disgust may serve as distinct risk factors for obsessional content in youth with OCD. Future research should examine the predictive validity of DP and DS longitudinally, as well as examine effective ways to more effectively target DP with exposure therapy.
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Affiliation(s)
| | - Meghan Schreck
- McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - Maddi Gervasio
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital, USA
| | - Joshua Kemp
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital, USA
| | - Jennifer Freeman
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital, USA
| | - Abbe Garcia
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital, USA
| | - Brady Case
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital, USA
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Francis SM, Beard KL, Tseng A, Chen M, Gillick BT, Jacob S, Conelea CA. Transcranial direct current stimulation for compulsivity in adolescent fraternal twins with neurodevelopmental disorders. Brain Stimul 2020; 13:1153-1155. [PMID: 32413553 PMCID: PMC10895864 DOI: 10.1016/j.brs.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/03/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sunday M Francis
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA.
| | - Katie L Beard
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Angela Tseng
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Mo Chen
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA; Non-invasive Neuromodulation Laboratory, Brain Conditions Program, MnDRIVE Initiative, University of Minnesota, Minneapolis, MN, USA
| | - Bernadette T Gillick
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Suma Jacob
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Christine A Conelea
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
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32
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Fineberg NA, Hollander E, Pallanti S, Walitza S, Grünblatt E, Dell’Osso BM, Albert U, Geller DA, Brakoulias V, Janardhan Reddy Y, Arumugham SS, Shavitt RG, Drummond L, Grancini B, De Carlo V, Cinosi E, Chamberlain SR, Ioannidis K, Rodriguez CI, Garg K, Castle D, Van Ameringen M, Stein DJ, Carmi L, Zohar J, Menchon JM. Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders. Int Clin Psychopharmacol 2020; 35:173-193. [PMID: 32433254 PMCID: PMC7255490 DOI: 10.1097/yic.0000000000000314] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/16/2020] [Indexed: 11/25/2022]
Abstract
In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.
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Affiliation(s)
- Naomi A. Fineberg
- University of Hertfordshire, Hatfield
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Eric Hollander
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Stefano Pallanti
- Istituto di Neuroscienze, University of Florence, Firenze, Italy
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Susanne Walitza
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich
- Neuroscience Center Zurich, University of Zurich and ETH Zurich
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Edna Grünblatt
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich
- Neuroscience Center Zurich, University of Zurich and ETH Zurich
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Bernardo Maria Dell’Osso
- University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Psychiatry and Behavioural Sciences, Stanford University, California, USA
- CRC ‘Aldo Ravelli’ for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford
| | - Umberto Albert
- Department of Medicine, Surgery and Health Sciences, UCO Clinica Psichiatrica, University of Trieste, Trieste, Italy
| | - Daniel A. Geller
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vlasios Brakoulias
- Western Sydney Obsessive-Compulsive and Related Disorders Service, Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales
- Translational Research Health Institute (THRI), Clinical and Health Psychology Research Initiative (CaHPRI) and School of Medicine, Western Sydney University, Sydney, Australia
| | - Y.C. Janardhan Reddy
- OCD Clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Shyam Sundar Arumugham
- OCD Clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Roseli G. Shavitt
- OCD Spectrum Disorders Program, Institute and Department of Psychiatry, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo-SP, Brazil
| | - Lynne Drummond
- Consultant Psychiatrist, SW London and St George’s NHS Trust and St George’s, University of London, London
| | - Benedetta Grancini
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
- University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Vera De Carlo
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
- University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Eduardo Cinosi
- University of Hertfordshire, Hatfield
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
| | - Samuel R. Chamberlain
- Department of Psychiatry, University of Cambridge, Cambridge
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Konstantinos Ioannidis
- Department of Psychiatry, University of Cambridge, Cambridge
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Carolyn I. Rodriguez
- Department of Psychiatry and Behavioural Sciences, Stanford University, California, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Kabir Garg
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire
| | - David Castle
- St. Vincent’s Hospital Melbourne and The University of Melbourne, Melbourne, Australia
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Dan J. Stein
- SA MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Lior Carmi
- The Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan
- The Data Science Institution, The Interdisciplinary Center, Herzliya
| | - Joseph Zohar
- The Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan
- Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Jose M. Menchon
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain
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Uhre VF, Uhre CF, Lønfeldt NN, Pretzmann L, Vangkilde S, Plessen KJ, Gluud C, Jakobsen JC, Pagsberg AK. Dr. Uhre et al. Reply. J Am Acad Child Adolesc Psychiatry 2020; 59:787-791. [PMID: 32618274 DOI: 10.1016/j.jaac.2020.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/30/2020] [Accepted: 04/24/2020] [Indexed: 01/26/2023]
Abstract
In a recent letter to the editor, a group of clinician-researchers posit that the conclusions in our published systematic review1 on cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) are based on inappropriate methodology. In this reply, we address the concerns expressed by Storch et al.2.
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Affiliation(s)
- Valdemar Funch Uhre
- Child and Adolescent Mental Health Centre, Capital Region, Denmark; University of Copenhagen, Denmark; Danish Research Centre for Magnetic Resonance, Hvidovre Hospital, Denmark
| | - Camilla Funch Uhre
- Child and Adolescent Mental Health Centre, Capital Region, Denmark; University of Copenhagen, Denmark.
| | | | - Linea Pretzmann
- Child and Adolescent Mental Health Centre, Capital Region, Denmark
| | - Signe Vangkilde
- Child and Adolescent Mental Health Centre, Capital Region, Denmark; University of Copenhagen, Denmark
| | | | - Christian Gluud
- Copenhagen Trial Unit, Copenhagen, Denmark; The Cochrane Hepato-Biliary Group, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Centre, Capital Region, Denmark; University of Copenhagen, Denmark
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Cyr M, Pagliaccio D, Yanes-Lukin P, Fontaine M, Rynn MA, Marsh R. Altered network connectivity predicts response to cognitive-behavioral therapy in pediatric obsessive-compulsive disorder. Neuropsychopharmacology 2020; 45:1232-1240. [PMID: 31952071 PMCID: PMC7235012 DOI: 10.1038/s41386-020-0613-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/21/2019] [Accepted: 01/08/2020] [Indexed: 12/12/2022]
Abstract
Obsessive-compulsive disorder (OCD) is commonly associated with alterations in cortico-striato-thalamo-cortical brain networks. Yet, recent investigations of large-scale brain networks suggest that more diffuse alterations in brain connectivity may underlie its pathophysiology. Few studies have assessed functional connectivity within or between networks across the whole brain in pediatric OCD or how patterns of connectivity associate with treatment response. Resting-state functional magnetic resonance imaging scans were acquired from 25 unmedicated, treatment-naive children and adolescents with OCD (12.8 ± 2.9 years) and 23 matched healthy control (HC) participants (11.0 ± 3.3 years) before participants with OCD completed a course of cognitive-behavioral therapy (CBT). Participants were re-scanned after 12-16 weeks. Whole-brain connectomic analyses were conducted to assess baseline group differences and group-by-time interactions, corrected for multiple comparisons. Relationships between functional connectivity and OCD symptoms pre- and post-CBT were examined using longitudinal cross-lagged panel modeling. Reduced connectivity in OCD relative to HC participants was detected between default mode and task-positive network regions. Greater (less altered) connectivity between left angular gyrus and left frontal pole predicted better response to CBT in the OCD group. Altered connectivity between task-positive and task-negative networks in pediatric OCD may contribute to the impaired control over intrusive thoughts early in the illness. This is the first study to show that altered connectivity between large-scale network regions may predict response to CBT in pediatric OCD, highlighting the clinical relevance of these networks as potential circuit-based targets for the development of novel treatments.
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Affiliation(s)
- Marilyn Cyr
- Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY, USA. .,Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | - David Pagliaccio
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Paula Yanes-Lukin
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Martine Fontaine
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Moira A. Rynn
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Rachel Marsh
- grid.413734.60000 0000 8499 1112Division of Child and Adolescent Psychiatry, New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY USA
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de Jong R, Lommen MJJ, van Hout WJPJ, de Jong PJ, Nauta MH. Therapists' characteristics associated with the (non-)use of exposure in the treatment of anxiety disorders in youth: A survey among Dutch-speaking mental health practitioners. J Anxiety Disord 2020; 73:102230. [PMID: 32428821 DOI: 10.1016/j.janxdis.2020.102230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/27/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Although there is consensus that exposure is the key ingredient in treating childhood anxiety disorders, several studies in the USA suggest exposure to be underused in clinical practice. Previous research pointed to therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety as important factors in the underusage of exposure in the treatment of adult anxiety disorders. This study examined what therapist characteristics may be involved in the (non-)use of exposure in treating childhood anxiety disorders. METHODS An internet-based survey among 207 youth mental health care professionals in the Netherlands and Belgium was conducted to assess therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety, depression and stress. RESULTS The current survey showed that therapists used exposure in about half of their cases of childhood anxiety and that the non-use was independently associated with the relatively strong negative beliefs about exposure, therapists' age, and non-CBT orientation. DISCUSSION Findings point to the importance of addressing negative beliefs about exposure in therapists' training and supervision to resolve therapy drift away from exposure, and consequently improve utilization and delivery of exposure-based therapy for childhood anxiety disorders.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Peter J de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
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Peris TS, Rozenman MS, Bai S, Perez J, Thamrin H, Piacentini J. Ethnicity moderates outcome in family focused treatment for pediatric obsessive compulsive disorder. J Anxiety Disord 2020; 73:102229. [PMID: 32361032 DOI: 10.1016/j.janxdis.2020.102229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 03/23/2020] [Accepted: 04/17/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE This study examined predictors and moderators of treatment outcome in a randomized controlled trial (RCT) comparing two active interventions for pediatric obsessive compulsive disorder that differed with respect to the focus and format of family intervention. We had a particular interest in the role of race/ethnicity in shaping outcomes given our relatively diverse sample composition and the limited prior work in this area. METHOD A total of 62 youths (Mean age = 12.71 years; 57 % male; 34 % non-white) were assigned to either a standard cognitive behavioral therapy (CBT) family intervention (ST) or to a tailored intervention designed for cases of OCD complicated by poor family functioning (Enhanced Family Therapy; ET). Treatment in both arms involved 12 sessions of exposure therapy; the family interventions differed. Predictor and moderator variables were chosen based on the extant literature. RESULTS Minority status did not predict outcome, suggesting that overall, white and non-white youth had comparable treatment response. Race/ethnicity did, however, moderate response with non-white youth faring better in the ET arm of the study. In particular, minority youth in ET had, on average, post-treatment CYBOCS scores consistent with clinical remission whereas their ST counterparts were left with symptoms considered moderately severe. There were no predictors of treatment outcome. CONCLUSIONS Minority status predicts poorer response to standard CBT across disorders, suggesting the need for possible treatment adaptations. The present findings highlight one avenue for matching patients to treatments that might optimize outcomes and underscore the value of family involvement in OCD treatment.
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Affiliation(s)
- Tara S Peris
- Jane and Semel Institute for Neuroscience and Human Behavior, United States.
| | | | - Sunhye Bai
- Pennsylvania State University, United States
| | - Jocelyn Perez
- Jane and Semel Institute for Neuroscience and Human Behavior, United States
| | | | - John Piacentini
- Jane and Semel Institute for Neuroscience and Human Behavior, United States
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Nazeer A, Latif F, Mondal A, Azeem MW, Greydanus DE. Obsessive-compulsive disorder in children and adolescents: epidemiology, diagnosis and management. Transl Pediatr 2020; 9:S76-S93. [PMID: 32206586 PMCID: PMC7082239 DOI: 10.21037/tp.2019.10.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Obsessive-compulsive disorder (OCD) can be found in about 4% of the general population and is characterized by various compulsions and obsessions that interfere with the person's quality of life from a mild to severe degree. The following discussion reflects on current concepts in this condition, including its epidemiology and etiologic underpinnings (behavioral, neurological, immunological, gastroenterological, as well as genetic). The interplay of PANS and PANDAS are included in this review. In addition, the core concepts of OCD diagnosis, differential diagnosis, and co-morbidities are considered. It is stressed that the quality of life for persons with pediatric OCD as well as for family members can be quite limited and challenged. Thus, principles of management are presented as a guide to improve the quality of life for these persons as much as possible.
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Affiliation(s)
- Ahsan Nazeer
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, Sidra Medicine, Doha, Qatar
| | - Finza Latif
- Division of Psychiatry and Behavioral Sciences, George Washington University, Children's National Medical Center, Washington, DC, USA
| | - Aisha Mondal
- Division of Psychiatry and Behavioral Sciences, George Washington University, Children's National Medical Center, Washington, DC, USA
| | | | - Donald E Greydanus
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder. J Anxiety Disord 2020; 69:102151. [PMID: 31864218 DOI: 10.1016/j.janxdis.2019.102151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/16/2019] [Accepted: 10/09/2019] [Indexed: 11/23/2022]
Abstract
PURPOSE Current guidelines for first-line treatment of childhood OCD are cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP), and/or antidepressant (ADM) pharmacotherapy, specifically serotonin reuptake inhibitors (SRI). Given that first-line are relatively similar in terms of clinical effectiveness, the role of costs to provide such services may help influence treatment decisions. In the case of treatment refractory pediatric OCD, this cost-effectiveness analysis (CEA) aims to further evaluate two additional, higher intensity combination therapies, namely OCD-specific Intensive Outpatient (IOP) and Partial Hospitalization Programs (PHP), to determine the additional benefits, in terms of effectiveness, that may result, and the corresponding increase in costs for these higher-intensity courses of therapy. RESULTS IOP was the most cost-effective strategy in terms of change in CY-BOCS, pre/post treatment, equal to 16.42 units, followed by PHP and CBT monotherapy augmented with ADM CBT-monotherapy augmented with additional CBT and ADM-only augmented with CBT followed closely with 15.56 and 14.75 unit improvements in CY-BOCS. IOP accomplished its superior cost-effectiveness with an Incremental Cost-Effectiveness Ratio (ICER), of $48,834, lower than either of the established willingness to Pay thresholds. CONCLUSIONS Lack of access to high fidelity, high dose CBT paired with pharmacotherapy is an issue for OCD patients and families. Among youth who were treatment non-responsive, these results indicate the superiority of a high dosage CBT strategy, indicating the need to increase access to these treatments.
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Systematic Review and Meta-Analysis: Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in Children and Adolescents. J Am Acad Child Adolesc Psychiatry 2020; 59:64-77. [PMID: 31589909 DOI: 10.1016/j.jaac.2019.08.480] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 07/17/2019] [Accepted: 09/27/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess benefits and harms of cognitive-behavioral therapy (CBT) versus no intervention or versus other interventions for pediatric obsessive-compulsive disorder (OCD). METHOD We searched for randomized clinical trials of CBT for pediatric OCD. Primary outcomes were OCD severity, serious adverse events, and level of functioning. Secondary outcomes were quality of life and adverse events. Remission from OCD was included as an exploratory outcome. We assessed risk of bias and evaluated the certainty of the evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Nine trials (N = 645) were included comparing CBT with no intervention and 3 trials (N = 146) comparing CBT with selective serotonin reuptake inhibitors (SSRIs). Compared with no intervention, CBT decreased OCD severity (mean difference [MD] = -8.51, 95% CI = -10.84 to -6.18, p < .00001, low certainty), improved level of functioning (patient-rated: standardized MD [SMD] = -0.90, 95% CI = -1.19 to -0.62, p < .00001, very low certainty; parent-rated: SMD = -0.68, 95% CI = -1.12 to -0.23, p = .003, very low certainty), had similar proportions of participants with adverse events (risk ratio = 1.06, 95% CI = 0.93-1.22, p = .39, GRADE: low certainty), and was associated with reduced risk of still having OCD (risk ratio = 0.50, 95% CI = 0.37-0.67, p < .00001, very low certainty). We had insufficient data to assess the effect of CBT versus no intervention on serious adverse events and quality of life. Compared with SSRIs, CBT led to similar decreases in OCD severity (MD = -0.75, 95% CI = -3.79 to 2.29, p = .63, GRADE: very low certainty), and was associated with similar risk of still having OCD (risk ratio = 0.85, 95% CI = 0.66-1.09, p = .20, very low certainty). We had insufficient data to assess the effect of CBT versus SSRIs on serious adverse events, level of functioning, quality of life, and adverse events. CONCLUSION CBT may be more effective than no intervention and comparable to SSRIs for pediatric OCD, but we are very uncertain about the effect estimates.
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Law C, Boisseau CL. Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives. Psychol Res Behav Manag 2019; 12:1167-1174. [PMID: 31920413 PMCID: PMC6935308 DOI: 10.2147/prbm.s211117] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/17/2019] [Indexed: 11/23/2022] Open
Abstract
Numerous clinical trials support the efficacy of exposure and response prevention (ERP) for the treatment of obsessive-compulsive disorder (OCD). Accordingly, ERP has been formally recognized as a first-line, evidence-based treatment for OCD. This review discusses the theoretical underpinnings of the treatment from a behavioral and neurobiological perspective and summarizes the evidence supporting the efficacy of ERP across child and adult populations. Next, we discuss predictors of ERP treatment outcome and discuss implementation strategies designed to improve feasibility and adoption. Finally, strategies to improve treatment dissemination are discussed.
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Affiliation(s)
- Clara Law
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christina L Boisseau
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Aspvall K, Andersson E, Lenhard F, Melin K, Norlin L, Wallin L, Silverberg-Mörse M, Feldman I, Bottai M, Mataix-Cols D, Serlachius E. Stepped Care Internet-Delivered vs Face-to-Face Cognitive-Behavior Therapy for Pediatric Obsessive-Compulsive Disorder: A Trial Protocol for a Randomized Noninferiority Trial. JAMA Netw Open 2019; 2:e1913810. [PMID: 31642928 PMCID: PMC6820063 DOI: 10.1001/jamanetworkopen.2019.13810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/04/2019] [Indexed: 01/10/2023] Open
Abstract
Importance Internet-delivered cognitive behavior therapy is an effective treatment for children and adolescents with obsessive-compulsive disorder and has the potential to markedly increase access to treatment for patients while being cost-effective for health care organizations. Objective To investigate whether internet-delivered cognitive behavior therapy implemented within a stepped care model is noninferior to, and cost-effective compared with, the gold standard of face-to-face cognitive behavior therapy for pediatric obsessive-compulsive disorder. Design, Setting, and Participants Multicenter, single-blind, randomized clinical noninferiority trial implemented at 2 specialist pediatric obsessive-compulsive disorder clinics in Stockholm and Gothenburg, Sweden. Participants are 152 children and adolescents aged 7 to 17 years with obsessive compulsive disorder, recruited through the 2 clinics and online self-referral. Patients will be randomized 1:1 to the stepped care intervention or face-to-face therapy. Blind evaluations will be conducted after treatment and at 3-month and 6-month follow-ups. At the 6-month follow-up (primary end point), noninferiority will be tested and resource use will be compared between the 2 treatment groups. Data will be analyzed according to intention-to-treat principles. Intervention Patients randomized to stepped care will first receive internet-delivered cognitive behavior therapy for 16 weeks; patients who are classified as nonresponders 3 months after treatment completion will receive additional face-to-face therapy. The control group will receive 16 weeks of face-to-face cognitive behavior therapy immediately following randomization and nonresponders at the 3-month follow-up will, as in the stepped care group, receive additional face-to-face therapy. Main Outcomes and Measures Noninferiority is defined as a 4-point difference on the primary outcome measure (Children's Yale-Brown Obsessive Compulsive Scale). Discussion Recruitment started October 6, 2017, and was completed May 24, 2019. Results from the primary end point will be available by May 2020. The naturalistic follow-ups (1, 2, and 5 years after the end of treatment) will continue to 2025. There are no interim analyses planned or stopping rules for the trial. Trial Registration ClinicalTrials.gov identifier: NCT03263546.
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Affiliation(s)
- Kristina Aspvall
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Erik Andersson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fabian Lenhard
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Karin Melin
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Specialized Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lisa Norlin
- Department of Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Specialized Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lena Wallin
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Specialized Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Inna Feldman
- Department of Women's and Children's Health, Uppsala Universitet, Uppsala, Sweden
| | - Matteo Bottai
- Institute of Environmental Medicine, Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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42
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Albert U, Di Salvo G, Solia F, Rosso G, Maina G. Combining Drug and Psychological Treatments for Obsessive- Compulsive Disorder: What is the Evidence, When and for Whom. Curr Med Chem 2019; 25:5632-5646. [PMID: 28707590 DOI: 10.2174/0929867324666170712114445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 04/11/2017] [Accepted: 05/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Serotonin reuptake inhibitors (SRIs) and cognitive-behavioral psychotherapy (CBT) are first-line treatments for obsessive-compulsive disorder (OCD). Since response is often inadequate, in recent years researchers investigated whether combining CBT and SRIs, either ab initio or sequentially, results in a greater reduction of obsessivecompulsive symptoms. OBJECTIVE The aims of the present paper are to assess if combination treatment seems adding benefits as compared to either monotherapy alone and if sequential strategies may be effective in converting partial or non responders to a first-line treatment into responders. METHOD We reviewed available literature on pharmacological and CBT combination and sequential treatments for adult and pediatric OCD patients and then we conducted a separate analysis for studies concerning these two promising strategies. Search results included openlabel trials and randomized controlled trials (RCTs). RESULTS We identified ten controlled studies assessing the efficacy of combination treatments ab initio versus CBT alone and six evaluating combination strategies ab initio versus medications alone. Eleven studies, only two of which were RCTs, have been published on sequential treatments. The combination ab initio of CBT and SRIs has not been found to be clearly superior to either monotherapy alone in most studies conducted on this topic, except for patients with severe depression who might benefit more from the combination versus only CBT. A sequential administration of CBT after medications has been found useful in promoting remission in patients who partially responded to drugs and in promoting response in resistant patients. CONCLUSION OCD patients with comorbid major depression should receive medication firstly, eventually associated with CBT; for all remaining patients there is clear evidence from the literature of no additive benefits of combining ab initio CBT and medication. Therefore, the routine use of a combination approach in all adult patients affected by OCD is not supported by the literature. The available evidence supports the effectiveness of the sequential addition of CBT to SRIs.
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Affiliation(s)
- Umberto Albert
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gabriele Di Salvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Francesca Solia
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Gianluca Rosso
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
| | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Italy, A.O.U. San Luigi Gonzaga of Orbassano, Turin, Italy
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43
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A Pediatric Infectious Disease Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated With Streptococcal Infection and Pediatric Acute-onset Neuropsychiatric Syndrome. Pediatr Infect Dis J 2019; 38:706-709. [PMID: 30747831 DOI: 10.1097/inf.0000000000002295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Solomon DT, Nietert PJ, Calhoun C, Smith DW, Back SE, Barden E, Brady KT, Flanagan JC. Effects of Oxytocin on Emotional and Physiological Responses to Conflict in Couples with Substance Misuse. ACTA ACUST UNITED AC 2019; 7:91-102. [PMID: 30740265 DOI: 10.1037/cfp0000103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Social stress, especially dyadic conflict among couples, is an important correlate of addiction. Several authors have suggested that the neuropeptide oxytocin (OT) may be useful in the treatment of couples with substance misuse. However, the literature examining OT among couples is scant and has yielded mixed findings. The current study examined the effects of OT versus placebo on emotional (e.g., warmth and anger) and physiological (e.g., skin conductance and heart rate) reactivity to a conflict resolution task in 30 heterosexual couples (N=60) in which one or both members misused substances. Using a randomized, double-blind, placebo-controlled design, both partners within each dyad were randomized to the same treatment condition. Participants completed a standardized conflict resolution task at baseline and 45 minutes following drug self-administration. Physiological measures were examined continuously during the laboratory tasks and emotional reactivity was self-reported at baseline and at 5 time points over the course of 1 hour following the second conflict resolution task. Results of a multi-level growth curve model accounting for baseline scores, gender and drug condition indicate that positive emotional experiences and skin conductance measures increased over the 5 time points. Neither drug condition nor gender was significantly related to outcomes, and no interaction effects were observed. These findings highlight the complexities involved in translational OT research and suggest that the impact of OT on key outcomes requires further exploration in regards to OT's potential therapeutic benefit.
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Affiliation(s)
| | | | - Casey Calhoun
- Medical University of South Carolina, Charleston, SC
| | | | - Sudie E Back
- Medical University of South Carolina, Charleston, SC.,Ralph H. Johnson VAMC, Charleston, SC
| | - Eileen Barden
- Medical University of South Carolina, Charleston, SC
| | - Kathleen T Brady
- Medical University of South Carolina, Charleston, SC.,Ralph H. Johnson VAMC, Charleston, SC
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45
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Gilbert DL, Mink JW, Singer HS. Reply. J Pediatr 2019; 204:324-325. [PMID: 30243541 DOI: 10.1016/j.jpeds.2018.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Donald L Gilbert
- Pediatrics and Neurology Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
| | - Jonathan W Mink
- Frederick A. Horner, MD Endowed Professor in Pediatric Neurology, Neurology, Neuroscience, and Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Harvey S Singer
- Pediatrics and Neurology Johns Hopkins Hospital Baltimore, Maryland
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46
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Abstract
Obsessive-compulsive disorder (OCD) affects 1%-3% of children worldwide and has a profound impact on quality of life for patients and families. Although our understanding of the underlying etiology remains limited, data from neuroimaging and genetic studies as well as the efficacy of serotonergic medications suggest the disorder is associated with the fundamental alterations in the function of cortico-striato-thalamocortical circuits. Significant delays to diagnosis are common, ultimately leading to more severe functional impairment with long-term developmental consequences. The clinical assessment requires a detailed history of specific OCD symptoms as well as psychiatric and medical comorbidities. Standardized assessment tools may aid in evaluating and tracking symptom severity and both individual and family functioning. In the majority of children, an interdisciplinary approach that combines cognitive behavioral therapy with a serotonin reuptake inhibitor leads to meaningful symptom improvement, although some patients experience a chronic, episodic course. There are limited data to guide the management of treatment-refractory illness in children, although atypical antipsychotics and glutamate-modulating agents may be used cautiously as augmenting agents. This review outlines a clinical approach to the diagnosis and management of OCD, highlighting associated challenges, and limitations to our current knowledge.
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Affiliation(s)
- Clara Westwell-Roper
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - S Evelyn Stewart
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada.,BC Children's Hospital Research Institute, Vancouver, Canada.,BC Mental Health and Substance Use Research Institute, Vancouver, Canada
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47
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Affiliation(s)
- Tamara Pringsheim
- From the Department of Clinical Neuroscience, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alta., Canada (Pringsheim); and the Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles Semel Institute, Los Angeles, Calif., USA (Piacentini)
| | - John Piacentini
- From the Department of Clinical Neuroscience, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alta., Canada (Pringsheim); and the Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles Semel Institute, Los Angeles, Calif., USA (Piacentini)
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48
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Cancilliere MK, Freeman J, Garcia A, Benito K, Sapyta J, Franklin M. Assessing Acute Secondary Treatment Outcomes in Early-Onset Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev 2018; 49:718-729. [PMID: 29435695 DOI: 10.1007/s10578-018-0786-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Obsessive-compulsive disorder (OCD) in children under 8 years of age, referred to as early-onset OCD, has similar features to OCD in older children, including moderate to severe symptoms, impairment, and significant comorbidity. Family-based cognitive behavioral therapy (FB-CBT) has been found efficacious in reducing OCD symptoms and functional impairment in children ages 5-8 years with OCD; however, its effectiveness on reducing comorbid psychiatric symptoms in this same population has yet to be demonstrated. This study examined the acute effects of FB-CBT vs. family-based relaxation treatment over 14 weeks on measures of secondary treatment outcomes (non-OCD) in children with early-onset OCD. Children in the FB-CBT condition showed significant improvements from pre- to post-treatment on secondary outcomes, with a decrease in overall behavioral and emotional problems, internalizing symptoms, as well as overall anxiety symptom severity. Neither condition yielded significant change in externalizing symptoms. Clinical implications of these findings are considered.
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Affiliation(s)
- Mary Kathryn Cancilliere
- Department of Psychology, University of Rhode Island, 10 Chafee Road, Suite 8, Kingston, RI, 02881, USA.
| | - Jennifer Freeman
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Abbe Garcia
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Jeffrey Sapyta
- Duke Child and Family Study Center, Duke University School of Medicine, Durham, NC, USA
| | - Martin Franklin
- Child and Adolescent OCD, Tic, Trich, and Anxiety Group, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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49
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Effects of the First Step to Success Intervention on Preschoolers with Disruptive Behavior and Comorbid Anxiety Problems. SCHOOL MENTAL HEALTH 2018; 10:243-253. [PMID: 33343758 DOI: 10.1007/s12310-017-9226-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Preschoolers with elevated anxiety symptoms are at high risk not only for developing more severe mental health disorders in later life but are also apt to respond more poorly to intervention if they present with comorbid disruptive behavior. Because early signs of anxiety disorders may not be recognized as such in preschool settings, many children selected for Tier 2 interventions that target externalizing problem behaviors may also have co-occurring anxiety symptoms and disorders. The First Step to Success intervention has recently been adapted for preschoolers with externalizing behaviors and was found to be efficacious in a randomized controlled trial. The current report examines effects of the First Step intervention on a subsample of 38 preschoolers with comorbid anxiety symptoms. Compared to usual-care controls, preschoolers who were assigned to the First Step intervention demonstrated medium to large effects in reducing externalizing behavior and improving social functioning outcomes, but had small effects for reductions in internalizing behaviors. Implications for intervening with preschoolers at risk for comorbid disruptive and anxiety behaviors are discussed.
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50
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Freeman J, Benito K, Herren J, Kemp J, Sung J, Georgiadis C, Arora A, Walther M, Garcia A. Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating, Improving, and Transporting What Works. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2018; 47:669-698. [DOI: 10.1080/15374416.2018.1496443] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jennifer Freeman
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Kristen Benito
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Jennifer Herren
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Joshua Kemp
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Jenna Sung
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Christopher Georgiadis
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Aishvarya Arora
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Michael Walther
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Abbe Garcia
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
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